Download Peritoneal Dialysis Policy and Procedure

PERITONEAL DIALYSIS
TABLE OF CONTENTS
Purpose
Policy Statements
Site Applicability
Practice Level/Competencies
Definitions
Peritoneal Dialysis Clamping Kit
Policies and Procedures:
Setting Up & Initiating PD for Acute and Chronic Patients on Inpatient Unit 3F
Discontinuing Peritoneal Dialysis/Capping off the PD catheter
Monitoring and Care of Child on Peritoneal Dialysis
Changing a Transfer Set
Applying a Titanium Adapter (for Transfer Set Connection)
Adding Medications to the PD Solution
Heparin Flushing a PD catheter (with a Transfer Set)
Specimen Collection: Peritoneal Dialysis Effluent
Disconnecting and Capping Off the Peritoneal Dialysis Catheter
Exit Site Care - Post Peritoneal Dialysis Catheter Insertion
Exit Site Care - Chronic (Healed)
Documentation
References
Appendices
Appendix A: How to culture an incision or wound
Appendix B: Peritoneal Dialysis Exit Site Assessment Scoring System
PURPOSE
Peritoneal Dialysis is performed to remove fluids and toxins, regulate electrolyte levels and manage
azotemia via diffusion and osmosis. Indications for peritoneal dialysis include:
 hyperkalemia
 oliguria or anuria
 metabolic acidosis
 fluid overload unresponsive to diuretics
 combination of the above
 renal failure
Expected outcomes of peritoneal dialysis include:
 therapeutic goals of Peritoneal Dialysis are achieved
 catheter and access site is maintained without complications
 peritoneal dialysis access site functions properly
 respiratory status is adequate throughout treatment
 patient has acceptable levels of comfort
SITE APPLICABILITY
Peritoneal Dialysis is predominately done on the inpatient unit 3F.
PRACTICE LEVEL/COMPETENCIES
Peritoneal Dialysis is an advanced skill and is practiced after the practitioner has obtained the required
education and has had his/her learning validated at the bedside with the appropriate Dialysis Training
Nurse.
Established: 1988
Reviewed: 01 FEB 2012
Page 1 of 24
PERITONEAL DIALYSIS
DEFINITIONS
Azotemia - is a medical condition characterized by abnormally high levels of nitrogen-containing
compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds
in the blood. It is largely related to insufficient filtering of blood by the kidneys. It is characterized by a
decrease in the glomerular filtration rate (GFR) and increases in blood urea nitrogen (BUN) and serum
creatinine concentrations.
Dialysis fluid/dialysate- prescribed sterile solution of specific concentrations to facilitate diffusion and
osmosis across the peritoneal membranes.
Fill volume — the amount of dialysate prescribed to fill the peritoneal cavity per each cycle or run. The
prescribed fill volume is based on weight or BSA of the child and is adjusted for numerous factors (e.g.
patient’s tolerance, more solute or fluid removal) in conjunction with the input of the nephrologist. Too small
fill volumes may lead to rapid solute equilibration and inadequate ultrafiltration, too large fill volumes can
lead to excessive increases in intra-peritoneal pressure that reduces dialysis efficiency due to enhanced
lymphatic uptake. Excessive fill volumes may be associated with discomfort/pain, respiratory complications,
hernia, gastroesophageal reflux, and hydrothorax.
Effluent- dialysis fluid (fill volume) plus ultrafiltrate and waste removal emptied from the peritoneal cavity.
Ultrafiltrate – fluid and substances that have passed through the semipermeable membrane during
dialysis. Calculated by subtracting dialysis fluid (fill volume) from the effluent volume.
Hand Hygiene: Refer to Infection Control Manual Policy and Procedure for Handwashing
Peritoneal Dialysis (PD) – A therapy where solutes and water are transported across the peritoneum (a
semi-permeable membrane), utilizing a commercially prepared sterile solution which is introduced into and
removed from the peritoneal cavity. The solution used is formulated to assist in the removal of toxins and
regeneration of bicarbonate and removal of excess total body water and salt.
 Intermittent PD (IPD): Dialysis solution is present in the peritoneal cavity from time to time
usually ranging from 15-20 exchanges per day, 3-4 days per week.
 Continuous Ambulatory PD (CAPD): Dialysis solution is always present in the peritoneal
cavity. New solution is exchanged typically 3-5 times per day and performed manually by using
gravity to move fluid into and out of the peritoneal cavity.
 Continuous Cycling PD (CCPD): Dialysis solution is always present in the peritoneal cavity
where 6-12 night exchanges per day are performed by an automated machine (cycler) with a
last fill dwelling throughout the day. This enables the patient to be disconnected from the
machine and free to do normal daytime activities.
Phases of an Exchange:
PD involves repeated fluid exchanges or cycles:
Instillation or Fill Phase – dialysis solution is infused
into the peritoneal cavity through an abdominal
catheter.
Dwell Phase – dialysate remains in the peritoneal
cavity, which allows osmosis and diffusion to occur.
Dwell time varies based on the child’s clinical need and
is prescribed by the responsible physician. Shorter
dwell times increase ultrafiltration and urea clearance.
Longer dwell times favour higher creatinine and
phosphate clearance but may reduce ultrafiltration.
Drain Phase – the dialysate and the excess
extracellular fluid, wastes, and electrolytes are drained
from the peritoneal cavity via the peritoneal catheter.
Established: 1988
Reviewed: 01 FEB 2012
Page 2 of 24
PERITONEAL DIALYSIS
Peritoneal Catheter – permits the infusion of dialysis fluid into the peritoneal space and the movement of
water and associated solutes out of the peritoneal space.
Peritoneal Catheter
Placement
Straight and Curled PD catheters
Titanium adapters are adapters used to secure a Transfer Set or Dialysis Tubing to the PD catheter.
They are lightweight and resistant to electrolyte-containing solutions and result in a tighter connection than
plastic adapters. They do not chafe the catheter which can cause cracks or holes to develop.
Transfer Set – an extension tubing that attaches to the PD catheter at the skin level exit site. The transfer
set remains in place between PD therapy and is replaced every 6 months or sooner if concerns regarding
compromise of the transfer set integrity, post contamination episode or if recurrent/relapsing peritonitis.
Initiation of Peritoneal Dialysis requires a physician’s written order. The order must be patient specific
and include dialysis solution/concentration, fill volume, dwell time, frequency, last fill, number of cycles,
and if heparin is to be added.
The addition of medications to dialysate solution requires a physician’s written order. The order must be
patient specific and include drug name, dosage, route, and frequency.
Strict aseptic technique is required during peritoneal dialysis catheter access to reduce the risk of
peritoneal infection.
Peritoneal dialysis systems are changed every 96 hours or if system otherwise becomes contaminated.
An emergency clamping kit must always be prepared and available at the bedside.
Peritoneal Dialysis Emergency Clamping Kit
 UltraClamp (Red) Clamp
 2% Chlorhexidine/70% alcohol swabs
 Sterile towel
 Minicaps
Established: 1988
Reviewed: 01 FEB 2012
Page 3 of 24
PERITONEAL DIALYSIS
Setting Up and Initiating PD for Acute and Chronic Patients on Inpatient Unit 3F
Policy Statements
Both acute and chronic dialysis may be initiated utilizing either a Y-set System or the HomeChoice Pro
Cycler. Differences in the prescription, dwell volumes used, cycle lengths and frequency are the main
differences seen when comparing Acute to Chronic PD prescriptions and will be decided by the
Nephrologist in consideration of the individual patient.
Initiation of Peritoneal Dialysis requires consent from the family or guardian and written orders by the
Nephrologist. These orders must be patient specific and include the choice of dialysis solution and
concentration, fill volume, inflow/dwell and drain times and cycle numbers if using a Y-set or total
prescription time and cycle number if using Cycler. The choice of a last fill (if patient will be capped off) in
terms of dialysis solution/ concentration and volume must also be specified.
The addition of ALL medications to any PD solution requires a Nephrologist’s written order. The order must
be patient specific and include drug name, dosage in both concentration and preferably also in total
amount added per volume, route, and frequency and or orders for monitoring.
Aseptic technique is required during peritoneal dialysis catheter access to reduce the risk of peritonitis.
Peritoneal dialysis Y-set tubing is changed every 96 hours and cycler tubing every 24 hours or if the
system otherwise becomes contaminated. Dialysis solutions are changed every 24 hours or as directed
from the Stability Chart when medications are added. Please refer to the Stability Chart of Medications.
ALL infants and children receiving peritoneal dialysis MUST be weighed daily. This should occur on the
same scale, same time (every 24 hours), same clothes, and following first morning void (if able). The child
should be fully drained of their dwell, and weights must be recorded based on this “empty” weight.
Clinically unstable patients, or those with other concerns may require more frequent weights and this is at
the discretion of the Nephrologist.
Dialysis fluid is heated between 36 to 37 degrees Celsius prior to instillation. At no time will this fluid be
heated via microwave; rather the Home Choice may be used to warm and maintain appropriate
temperature for both cycler fluid and even dialysate bags used for the Y-set.
PROCEDURE
Rationale
1. IDENTIFY patient and ENSURE patient and family Evaluates and reinforces understanding of
understand procedure and questions are answered previously taught information.
(as appropriate)
2. OBTAIN and VERIFY Peritoneal Dialysis prescription
from physician.
3. GATHER needed equipment and supplies:
Cycler system:
Y-Set System:
 Dialysis
fluid
 Dialysis fluid as per
concentration as per
physician’s orders
physician’s orders
 PD Administration Set
 Cycler
set
with
(Y-Set)
cassette (Standard or
 PD Collection drainage
Low-recirculation)
bag
 12 ft. Drain Line or
 IV pole
Drain bag (15L x2)
 Mask
 Drain manifold (if
 Micropore (paper) tape
using drain bag)
 Sterile 4X4 gauze
 Mask
 Cycler (to use as a
warmer)
Established: 1988
Reviewed: 01 FEB 2012
Page 4 of 24
PERITONEAL DIALYSIS
MASK and PERFORM hand hygiene.
Standard/routine precautions.
PERFORM the 7 checks of a dialysis bag:
Reduces errors and risk of contamination.
 Right concentration
 Right Volume
 Expiration date
 Clear Solution
 No Leaks/Holes
 Intact Frangible/Seal
 Intact Port
For Y-Set System:
6. CLOSE all clamps on tubing then CONNECT tubing
to bags by luer lock.
7. ATTACH drain bag to drain line.
8. SECURE lines to pole using tape.
9. FILL one buretrol with 70 millilitres (mL). INVERT the
drip chamber filling it halfway. CLOSE clamp and
return drip chamber to upright position.
10. OPEN regulating clamp below chamber to prime
tubing to end. CLOSE clamp.
11. FILL second buretrol allowing solution to run through
drip chamber and into drain bag. Close roller clamp.
12. OPEN clamp on end of drainage bag to empty
priming solution.
13. PLACE clean towel underneath transfer set.
14. PERFORM hand hygiene.
Standard/routine precautions.
15. REMOVE Minicap from patient’s transfer set and
CONNECT tubing to transfer set by luer lock.
16. OPEN drain line allowing fluid to drain from the
Repositioning patient may assist with drainage.
patient.
17. CLOSE drain line when drainage ceases.
18. MEASURE amount of drainage/effluent and observe
the appearance.
19. FILL buretrol with prescribed volume + 10 mL
Ensure 10 mL remains in bottom of buretrols to
avoid trapping air in the line
20. FILL patient with prescribed amount.
4.
5.
NOTE: For an acute patient needing PD immediately,
patient should be supine during the dwell time and
started with small volume exchanges to prevent
abdominal leak and risk of peritonitis.
21. DWELL patient for amount of time ordered.
22. REPEAT steps (drain, fill, dwell) for a complete
exchange/cycle as ordered.
During the dwell time, the dialysis solution bags
are put on the cycler for warming.
Drain, fill, dwell is considered 1 complete
exchange/cycle.
NOTE: Patient may need 3 quick flushes (no dwell time)
for:
 clearing blood in the peritoneal cavity (post
catheter insertion)
Established: 1988
Reviewed: 01 FEB 2012
Page 5 of 24
PERITONEAL DIALYSIS


ensuring the patency of the PD catheter
severe abdominal pain for suspected peritonitis
(this is done prior to antibiotic administration)
 contamination
For Cycler:
6. TURN on the cycler machine.
7. SCROLL down to “Change Program”
8. ENTER dialysis prescription as per physician’s
orders.
9. PRESS STOP to complete entry.
10. PRESS GO to set up the cycler. Refer to “Home
Choice PRO Automated PD Systems: Patient AtHome Guide”
11. CHECK patient line for air.
12. PLACE clean towel underneath transfer set.
13. MASK and PERFORM hand hygiene.
Standard/routine precautions; Reduces
transmission of microorganisms and
contamination.
14. REMOVE Minicap from patient’s transfer set and
CONNECT tubing to transfer set by luer lock.
15. OPEN transfer set and PRESS GO to commence
Initiates dialysis.
treatment.
NOTE: Patient may need 3 quick flushes (bypassing the
dwell phase) for:
o severe abdominal pain for suspected
peritonitis (this is done prior to antibiotic
administration)
o contamination
Established: 1988
Reviewed: 01 FEB 2012
Page 6 of 24
PERITONEAL DIALYSIS
Discontinuing Peritoneal Dialysis/Capping off the PD Catheter
Rationale
PROCEDURE
1. DRAIN dialysate from peritoneal cavity and CLAMP
the catheter and the PD tubing once the effluent is
completely drained.
2. PERFORM hand hygiene and GATHER needed
equipment and supplies:
 Mask
 Securing device or tape
 Povidone-iodine impregnated sterile cap
(e.g. Baxter Opticap or Minicap)
 Clean field
3. MASK and PERFORM hand hygiene.
4. PLACE catheter on clean field. Aseptically, OPEN
povidone-iodine impregnated cap from package.
5. DISCONNECT the catheter from the PD tubing and
CONNECT povidone-iodine impregnated cap to end of
transfer set tubing.
6. SECURE catheter to abdomen by using a securing
device or tape.
Facilitates completion of task in a timely manner.
Standard/routine precautions.
Reduces transmission of microorganisms and
contamination from airborne pathogens.
Avoids trauma to exit site or dislodgement of
catheter; excessive movement interferes with
epithelialization and healing of the exit site.
Established: 1988
Reviewed: 01 FEB 2012
Page 7 of 24
PERITONEAL DIALYSIS
Monitoring and Care of Child Receiving Peritoneal Dialysis
Monitor for complications and adverse outcomes in patients receiving peritoneal dialysis such as:
 Electrolyte imbalances
 Excessive fluid gains or losses
 Drainage or leakage from the exit site
 Infection
 Bowel perforation
 Dislodgement or disconnection of the PD catheter or tubings
 Respiratory complications
GUIDELINES
Rationale
1. PERFORM and RECORD pre-dialysis daily weights. Patient weights are important in guiding ongoing
treatment.
2. PERFORM baseline and ongoing assessments
Establishes a baseline before therapy and
including:
monitoring through treatment for complications
and unexpected outcomes.
 Vital signs
 Presence of edema
 Intake and output
 Abdominal assessment
3. MONITOR laboratory results throughout treatment. Fluids and electrolytes shift during PD therapy.
4. MONITOR the integrity of the PD setup.
Disconnection in the setup provides a portal of
entry for pathogens, which can lead to peritonitis.
5. MONITOR for any difficulty filling or draining.
Children may need repositioning to facilitate flow
through the PD catheter.
Catheters may become kinked or obstructed.
Fibrin clots can obstruct drainage – heparin may
be added to the dialysate to prevent this.
If clotting is suspected, antithrombotic agents
may be required.
Established: 1988
Reviewed: 01 FEB 2012
Page 8 of 24
PERITONEAL DIALYSIS
Changing the Transfer Set
Policy Statements
A transfer set attachment to the PD catheter is required to enable a closed system upon
discontinuation/disconnection from PD system. The transfer set is usually attached to the PD catheter at
time of insertion in the operating room. Thereafter, the transfer set is changed every 6 months to reduce
infection rate or sooner if concerns regarding compromise of the transfer set integrity, post contamination
episode or in recurrent/relapsing peritonitis. The Transfer Set must also be changed if the Titanium Adaptor
is changed.
PROCEDURE
Rationale
1. PERFORM hand hygiene and GATHER needed
Facilitates completion of task in a timely manner.
equipment and supplies:
Standard/routine precautions.
 70% alcohol and paper towel or disinfectant
There are 2 sizes of Transfer Sets – “Short” and
wipe
 Chlorhexidine (CHG) 2% solution with 70% “Extra Short.”
alcohol and Gauze 4x4 (3) or 3 large
The “Short” set is generally used unless a patient
CHG/alcohol swabs
is an infant or requests the “Extra Short”.
 Transfer Set (appropriate size – see rationale
When replacing a Transfer Set, the same length
for selection criteria)
 Minicap (povidone-iodine impregnated cap) set is used unless the nurse determines that the
other length would be more appropriate or the
 Clean towel or blue pad
patient requests it.
 Red UltraClamp Tubing Clamp
 Mask
 Sterile gloves
 Sterile dressing tray
2. IDENTIFY patient and ENSURE patient and family Evaluates and reinforces understanding of
understand procedure and questions are answered. previously taught information.
PLACE towel or blue pad under patient.
3. CLAMP the catheter close to the patient using the
Prevents leaking of fluid when transfer set
red UltraClamp tubing clamp.
removed.
4. CLEAN the working surface using 70% alcohol and a Standard/routine precautions; Reduces
paper towel or disinfectant wipe.
transmission of microorganisms and
contamination from airborne pathogens.
5. PREPARE supplies using aseptic technique.
6. MASK and PERFORM hand hygiene. DON sterile
gloves.
7. CLOSE twist clamp on new transfer set.
8. PLACE sterile drape over patient and EXPOSE the
catheter.
9. CLEANSE the connection site between the catheter Aseptic technique.
and transfer set with CHG soaked gauze/swab as
follows:
a. WRAP first gauze/swab around the
connection site, SCRUB for 1 minute, and
HOLD.
b. While holding the first gauze/swab around the
connection, CLEAN with the second gauze
from the connection site toward the patient up
to the red clamp, and DISCARD.
c. CLEAN with the third gauze/swab from the
Established: 1988
Reviewed: 01 FEB 2012
Page 9 of 24
PERITONEAL DIALYSIS
connection site away from the patient up to
the twist clamp of the Transfer Set and
DISCARD.
d. DISCARD first gauze/swab and allow
connection to dry for 1 minute.
10. DISCONNECT the old Transfer Set and DISCARD.
11. REMOVE the blue protective cap from the new
Transfer Set.
12. Tightly CONNECT the new Transfer Set to the
catheter via the adapter.
13. REMOVE the red UltraClamp from the catheter.
OPEN the twist clamp of the Transfer Set and, if
possible, allow fluid to drain into the Transfer Set.
14. CLOSE the twist clamp on the Transfer Set.
15. OPEN Minicap package, REMOVE the clear
protective end of the Transfer Set and ATTACH the
Minicap to the Transfer Set.
16. SECURE catheter and Transfer Set to patient using
immobilising device. ENSURE no kinks or tension
on the catheter when in the immobiliser.
17. DISCARD used supplies and equipment in
appropriate receptacle and PERFORM hand
hygiene.
Displaces air in the Transfer Set.
Stops flow of fluid.
Trauma to exit site can increase the risk of
bacterial growth followed by infections.
It is important to minimize catheter movement to
prevent fluid leaks from the exit site when
performing peritoneal dialysis.
Standard/routine precautions; reduces
transmission of microorganisms.
Established: 1988
Reviewed: 01 FEB 2012
Page 10 of 24
PERITONEAL DIALYSIS
Applying a Titanium Adapter (for Transfer Set Connection)
Policy Statements
A Titanium Adaptor is used with most catheters to connect the catheter to the Transfer Set or directly to the
dialysis tubing. It is added in the OR on all peritoneal dialysis catheters. The adapter will need to be
changed in the following circumstances:
a) Plastic adapter is in situ
b) Adapter is faulty
c) The distal catheter (adjacent to the titanium connection) is cracked or damaged (note if the
proximal catheter is cracked or damaged within 5 cm from exit site, insertion of a new PD
catheter is required).
PROCEDURE
Rationale
1. PERFORM hand hygiene and GATHER needed
Facilitates completion of task in a timely manner.
equipment and supplies:
Standard/routine precautions.
 70% alcohol and paper towel or disinfectant
wipe
 Chlorhexidine (CHG) 2% solution with 70%
alcohol and Gauze 4x4 (3) or 3 large
CHG/alcohol swabs
 Transfer Set
 Titanium Adapter (2 piece female luer lock)
 Minicap (povidone-iodine impregnated cap)
 Clean towel or blue pad
 Red UltraClamp Tubing Clamp
 Mask
 Sterile gloves
 Sterile scissors
 Sterile dressing tray
2. IDENTIFY patient and ENSURE patient and family Evaluates and reinforces understanding of
understand procedure and questions are answered. previously taught information.
PLACE towel or blue pad under patient.
3. CLAMP the catheter close to the patient using the
Prevents leaking of fluid when transfer set and
red UltraClamp tubing clamp.
adapter are removed.
4. CLEAN the working surface using 70% alcohol and a Standard/routine precautions; Reduces
paper towel or disinfectant wipe.
transmission of microorganisms and
contamination from airborne pathogens.
5. PREPARE supplies using aseptic technique.
6. MASK and PERFORM hand hygiene. DON sterile
gloves.
7. CLOSE twist clamp on new transfer set.
8. PLACE sterile drape over patient and EXPOSE the Aseptic technique.
catheter.
Prepares catheter for insertion of titanium
9. If distal end of the catheter is cracked or damaged
adapter.
and the adaptor is still in situ:
 WRAP first chlorhexidine soaked gauze/swab
around the damaged area of the catheter,
SCRUB for 1 minute, and HOLD in place.
 CLEAN with second chlorhexidine soaked
gauze/swab from the damaged area of the
catheter towards the patient up to the red
Established: 1988
Reviewed: 01 FEB 2012
Page 11 of 24
PERITONEAL DIALYSIS


clamp, and DISCARD.
With the third chlorhexidine soaked
gauze/swab, CLEAN from the damaged area
of the catheter away from the patient along
the Transfer Set up to the twist clamp. Allow
CHG to dry.
INSPECT and CUT below the damaged piece
(straight across, no angulation) using sterile
scissors.
If changing a Plastic Adaptor to a Titanium Adaptor:
 WRAP first CHG/alcohol soaked gauze at the
connection site, SCRUB for 1 minute, and
HOLD in place.
 CLEAN with second CHG/alcohol soaked
gauze from the connection site towards the
patient up to the red clamp, and DISCARD.
 With the third CHG/alcohol soaked gauze,
CLEAN from connection site away from the
patient along the Transfer Set up to the twist
clamp.
 CUT the catheter immediately proximal to the
old Adapter (straight across, no angulation)
using sterile scissors.
10. INSERT the narrow end of the titanium sleeve (non- Secures Titanium Adapter to PD catheter.
threaded end) onto the end of the exposed catheter,
then insert the luer end of the adapter all the way into
the catheter until fully advanced.
11. SLIDE the titanium sleeve back down towards the
adaptor and SCREW into the adaptor firmly.
12. CONNECT the new Transfer Set to the patient’s
catheter via the adapter as per steps 11-17 of
procedure for changing Transfer Set.
13. SEND the used Titanium Adaptor to Sterile
The titanium adapter is not disposable and must
Processing Department labelled “Return to Renal
be appropriately sterilized between uses.
Dialysis Unit”.
Established: 1988
Reviewed: 01 FEB 2012
Page 12 of 24
PERITONEAL DIALYSIS
Adding Medications to the PD Solution
Policy Statements
The addition of medications to dialysate solution requires a physician’s written order. The order must be
patient specific and include drug name, dosage, route, and frequency.
PROCEDURE
Rationale
1. PERFORM hand hygiene and GATHER needed
Facilitates completion of task in a timely manner.
equipment and supplies:
Standard/routine precautions.
 Chlorhexidine 2%/alcohol swabs 70%
 Syringe
 Needle
 Medication/Diluent if necessary
 Dialysis solution
2. OPEN and REMOVE the outer wrap from the dialysis
solution bag onto a surface cleansed with alcohol.
3. PERFORM the 7 checks of a dialysis bag:
Reduces error and risk of contamination.
 Right concentration
 Right Volume
 Expiration date
 Clear Solution
 No Leaks/Holes
 Intact Frangible/Seal
 Intact Port
4. PREPARE medication aseptically as per Mixing
Reduces transmission of microorganisms and
Medications for Parenteral Administration procedure. contamination.
5. SCRUB the peritoneal dialysis solution bag’s
To reduce the risk of peritonitis
medication port with a CHG/alcohol swab for 1
minute and allow to DRY.
6. INJECT prepared medication into the medication port
and WITHDRAW the needle.
7. INVERT the bag gently several times.
Ensures the medication has mixed well.
8. DISCARD used needle and syringe safely in a
sharps container.
Established: 1988
Reviewed: 01 FEB 2012
Page 13 of 24
PERITONEAL DIALYSIS
Heparin Flushing a PD Catheter
Policy Statements
A Peritoneal Dialysis Catheter is flushed weekly with heparin when catheter is not in use or more frequently
if there is prominent bloody dialysate. A physician’s order is required for flushing with heparin. The order
may specify “heparin flush peritoneal catheter as per protocol.”
The dose of heparin is 1 mL heparin (1000 units/mL) diluted with 7 mL NS to total volume 8 mL.
PROCEDURE
Rationale
1. REVIEW order for heparin flushing.
There is no clear evidence supporting the various
approaches to maintaining patency of a newly
placed catheter that is not being utilised (or
similarly an old PD catheter not being utilised
such as early post renal transplantation). In
these settings weekly flushing with heparin can
be employed. If there has been prominent bloody
dialysate during the post catheter insertion
dialysis exchanges, it is recommended (opinion).
Alternative strategies for PD catheter ‘break-in’
followed by other units include 1-3 times weekly
quick in/out exchange of eparinised (500u/L)
saline/ dianeal.
Facilitates completion of task in a timely manner.
2. GATHER needed equipment and supplies:
 Mask
 Vial normal saline
 Heparin 1000 units/mL vial
 10 mL syringe/needle
 Chlorhexidine 2%(CHG)/alcohol swab 70%
 Minicap (povidone-iodine impregnated cap)
3. MASK and PERFORM hand hygiene.
Standard/routine precautions.
4. SCRUB rubber top of heparin vial and saline vial with
CHG/alcohol swab and allow to dry.
5. DRAW 1 mL heparin (1000 units) and 7 mL saline
into syringe to a total of 8 mL.
6. CLOSE clamp on Transfer Set if not already closed Occludes catheter.
7. REMOVE Minicap.
8. ATTACH heparin syringe to Transfer Set, OPEN
Transfer Set clamp, and INJECT heparin/saline
solution.
9. CLOSE Transfer Set clamp and REMOVE syringe.
10. APPLY new Minicap to Transfer Set.
11. SECURE catheter and Transfer Set to patient using Trauma to exit site can increase the risk of
immobilising device. ENSURE no kinks or tension
bacterial growth followed by infections.
on the catheter when in the immobiliser.
It is important to minimize catheter movement to
prevent fluid leaks from the exit site when
performing peritoneal dialysis.
Established: 1988
Reviewed: 01 FEB 2012
Page 14 of 24
PERITONEAL DIALYSIS
Specimen Collection: Peritoneal Dialysis Effluent
Policy Statements
A cell count, gram stain and culture of effluent is obtained if peritonitis is suspected (e.g. cloudy dialysate
return, fever), or patient appears clinically septic.
Rationale
PROCEDURE
1. GATHER needed equipment and supplies:
Facilitates completion of task in a timely manner.
 Mask
Standard/routine precautions.
 Gloves
 2 C&S containers
 Minicap (povidone-iodine impregnated
cap) (not on treatment)
 50 mL syringe/#20 gauge needle
(CAPD)
 Chlorhexidine 2%(CHG)/alcohol 70%
swab (IPD, CAPD)
 Effluent Sample Bag (CCPD)
2. MASK and PERFORM hand. DON clean
gloves.
3. COLLECT specimens by one of the following methods depending on dialysis treatment used:
IPD







Obtain specimens
during a drain cycle
Carefully remove
spike from drainage
bag
Clean spike with
CHG/alcohol swab for
1 minute and let dry
Open drainage roller
clamp and collect 60
mL effluent directly
into the C&S container
Aseptically re-insert
drainage spike into
drainage bag
Open roller clamp
and continue with
drain cycle.
Pour 10 mL of
specimen collected
nd
into 2 C&S container
for cell count.
CCPD








Obtain specimens
during Initial Drain or
Drain 1
Close clamp on
sample bag
Connect bag to the
short line that forms a
“Y” on the drain line
(sample line). Save
caps in empty sterile
sample bag package
Position bag below
the level of the drain
line
After draining for 2
minutes, open clamps
When the sample bag
is full, close both
clamps
Disconnect sample
bag and recap sample
line (or cover with
sterile gauze)
Transfer 50 mL
sample into one C&S
container and 10 mL
in the other.
CAPD

Perform CAPD (twin
bag) according to
protocol
 Clean injection port
of drain bag with
CHG/alcohol swab for
1 minute and let dry
 Withdraw 60 ml
effluent from drain bag
using needle and
syringe
 Transfer 50 mL
sample into one C&S
container and 10 mL
in the other.







Not on Treatment (during
the day)
Connect sample bag to
transfer set
Open the twist clamp on
the Transfer Set and fill
sample bag with 60 mL
effluent (If patient has no
fluid to drain, fill patient with
their regular fill volume
preferably using CAPD and
dwell for 2 hours and then
obtain sample accordingly)
Close the twist clamp and
clamp the sample bag
Open Minicap package
Disconnect sample bag
from Transfer Set
Attach Minicap to
Transfer Set
Transfer 50 mL sample
into one C&S container and
10 mL in the other.
Established: 1988
Reviewed: 01 FEB 2012
Page 15 of 24
PERITONEAL DIALYSIS
4. LABEL containers with patient identification
and COMPLETE requisitions.
Ensures prompt identification and reporting of infectious
organisms to prompt initiation of appropriate treatment.
50 mL specimen for Culture and Sensitivity (C&S)
and gram stain, specifically request to “Please
report sensitivity to Vancomycin, cefazolin,
ceftazidne and tobramycin”.
10 mL specimen for cell count.
5. SEND specimens to laboratory. If peritonitis
is suspected, send to lab STAT.
Established: 1988
Reviewed: 01 FEB 2012
Page 16 of 24
PERITONEAL DIALYSIS
Disconnecting and Capping Off the Peritoneal Dialysis Catheter
Procedure
1. IDENTIFY patient and ENSURE patient and
family understand procedure and questions are
answered (as appropriate)
Rationale
Evaluates and reinforces understanding of
previously taught information.
2. CLOSE curtains around bed or door to room.
Standard/routine precautions;
Ensures privacy.
Facilitates completion of task in a timely manner.
3. GATHER the supplies:
o Clean towel
o Minicap ® or Opticap ® (check
expiration date on package.)
o Mask
4. PLACE a clean towel under catheter.
5. CLOSE the transfer set.
6. MASK and PERFORM hand hygiene.
Standard/routine precautions.
7. OPEN the Minicap or Opticap package.
8. DISCONNECT tubing from the transfer set.
9. PLACE Minicap on transfer set and luer lock
tightly. If using Opticap, PLACE the Minicap on
transfer set and screw on tightly and PLACE
second cap on patient-line tubing and luer lock
tightly.
Maintains asepsis.
Established: 1988
Reviewed: 01 FEB 2012
Page 17 of 24
PERITONEAL DIALYSIS
Exit Site Care – Post Peritoneal Dialysis Catheter Insertion
Policy Statements
In the immediate post-operative period, a peritoneal dialysis catheter exit site dressing is changed every 7
days for 2-3 weeks until healed and/or if a large amount of drainage is present. To minimize trauma and
promote adherence to the cuff and healing of the site, the catheter is to remain undisturbed as much as
possible.
PROCEDURE
Rationale
1. GATHER needed equipment and supplies:
Facilitates completion of task in a timely manner.

70% alcohol and paper towel or
disinfectant wipe
 Sterile Normal Saline
 3-6 packages of 2x2 gauze
 Sterile Q-tips
 Sterile gauze dressing (e.g. Mepore®)
 Sterile dressing tray
 Antibiotic ointment ordered
 Immobilizing device
 Clean gloves
 Sterile gloves
2. CLEAN the work surface area with 70% alcohol Standard/routine precautions; reduces transmission
and paper towel or disinfectant wipe.
of microorganisms.
3. MASK, PERFORM hand hygiene.
4. PREPARE equipment using aseptic technique.
5. DON clean gloves. REMOVE old dressing and
DISCARD.
6. REMOVE catheter from immobilizer.
7. ASSESS exit site for redness, swelling,
Culturing a site after cleansing is believed to be
tenderness, or drainage. If infection is suspected, more reflective of tissue bioburden than swabs of
NOTIFY physician. CULTURE site after
exudate.
cleansing in step 8.
If clear drainage is suspected, dip a glucose strip in
fluid to determine if potential leak
8. DISCARD gloves. PERFORM hand hygiene and Standard/routine precautions; reduces transmission
DON sterile gloves.
of microorganisms.
9. LIFT catheter with sterile gauze and clean the
There is evidence in surgical literature that wound
area around the catheter with saline-soaked
disinfectants, such as hydrogen peroxide and
gauze moving outward in a circular motion
providone iodine, can cause tissue damage and
covering a 5 cm radius around the exit site.
delay wound healing.
Repeat as needed until clean. CULTURE site if
needed
10. DRY the area around the catheter with dry gauze.
11. APPLY antibiotic ointment with sterile q-tips.
Antibiotic ointment is used as a preventative
measure to fight against gram-positive organisms
such as S. aureus and gram-negative such as
pseudomonas.
12. APPLY 4 – 2x2 gauze and gauze dressing (e.g. Trauma to exit site can increase the risk of bacterial
Mepore®) over exit site. Reinforce with a second growth followed by infections.
dressing if necessary.
It is important to minimize catheter movement to
Established: 1988
Reviewed: 01 FEB 2012
Page 18 of 24
PERITONEAL DIALYSIS
13. PLACE catheter in immobilizer device and
prevent fluid leaks from the exit site when
secure well not allowing any tension or kink in the performing peritoneal dialysis (PD). It is preferred to
line once secured
initiate PD 2 weeks post catheter insertion. If PD is
needed prior to 2 weeks, patient should be supine
during the dwell time and started with small volume
exchanges
14. DISCARD used supplies and equipment in
Standard/routine precautions; reduces transmission
appropriate receptacle.
of microorganisms.
Established: 1988
Reviewed: 01 FEB 2012
Page 19 of 24
PERITONEAL DIALYSIS
Exit Site Care – Chronic (Healed)
Policy Statements
A well healed chronic exit site does not require a dressing but needs to be cleansed and dried daily. It is
imperative that the peritoneal dialysis catheter be secured appropriately to prevent trauma to the exit site.
If a dressing is used on a healed site, it is changed daily and when it is grossly dirty or wet. Frequent
cleansing is essential to reduce resident bacteria.
The preferred timing for cleansing the exit site is following daily showering. If patient is unable to shower,
the site is cleansed daily using soap and water in the same manner.
Water submersion is contraindicated but infants and small children who do not shower may have tub baths
if the water is below the waist line (below exit site).
PROCEDURE
Rationale
1. PERFORM hand hygiene and GATHER needed Standard/routine precautions; reduces transmission
equipment and supplies:
of microorganisms.
 Clean wash cloth or gauze
 Liquid soap
 Q-Tips
 Antibiotic ointment ordered
 Sterile gauze dressing (e.g. Mepore®)
 Immobilizing device
2. REMOVE catheter dressing.
3. ASSESS exit site for redness, swelling,
As the subjective judgment of an exit-site status may
tenderness, or drainage. If infection is suspected, differ widely, it is imperative that objective criteria be
NOTIFY physician. CULTURE site after
used to diagnose an exit-site infection.
cleansing.
Culturing a site after cleansing is believed to be
 Refer to Exit Site Assessment Scoring
more reflective of tissue bioburden than swabs of
System to help determine if an
exudate.
infection is present.
 If clear drainage is suspected, dip a
glucose strip in fluid to determine if
potential leak.
4. SHOWER or BATHE as usual if showering or
bathing.
5. REMOVE catheter from immobilizer after shower. Keeps catheter immobilized while showering.
6. WASH around the catheter exit site with soap
and water using a clean wash cloth, moving
outward in a circular motion covering a 5-cm
radius around the exit site. Do not forcibly remove
crusting or scabs during cleansing because this
may traumatize the exit site, causing a break in
the skin and increasing the risk of infection.
CULTURE site if needed.
7. RINSE area in same manner and DRY the skin
around the catheter with a clean towel.
8. APPLY antibiotic ointment with q-tips
Antibiotic ointment is used as a preventative
measure to fight against gram-positive organisms
such as S. aureus and gram-negative organisms
such as pseudomonas.
Established: 1988
Reviewed: 01 FEB 2012
Page 20 of 24
PERITONEAL DIALYSIS
9. APPLY a gauze dressing over exit site if using. Trauma to exit site can increase the risk of bacterial
growth followed by infections.
10. PLACE catheter in immobilizer device and
secure well not allowing any tension or kink in the It is important to minimize catheter movement to
prevent fluid leaks from the exit site when
line once secured.
performing peritoneal dialysis (PD).
11. DISCARD used supplies and equipment in
Standard/routine precautions; reduces transmission
appropriate receptacle.
of microorganisms.
Established: 1988
Reviewed: 01 FEB 2012
Page 21 of 24
PERITONEAL DIALYSIS
DOCUMENTATION
Document on appropriate records including Peritoneal Dialysis Flowsheet, Nurses’ Notes, MAR, Patient
Care Flowsheet:
 Date and time of treatment initiation/discontinuation, transfer set change, Titanium Adaptor
application, specimens collected and reason
 Condition of peritoneal catheter and exit site assessment
 Exit site care
 Dressing changes
 Date and time of exchange
 Dialysis solution used (including additives), volume of dialysis fluid instilled, dwell time, amount
and appearance of effluent
 Medications added to dialysate (date, time, drug name, dosage, route)
 Intakes and output and peritoneal dialysis fluid balance (hourly and cumulative output totals)
 Heparin flushes (date, time, dosage, route)
 Daily weights
 Vital signs
 Child’s tolerance of procedure(s)
 Patient/Family Education
 Unexpected outcomes and complications
 any other pertinent actions or observations
REFERENCES
American Association of Critical Care Nurses. (2007). Procedure Manual for Pediatric Acute and Critical
Care. St. Louis: Elsevier.
Ash, S.R. Peritoneal Access Devices and Placement Techniques. In Nissenson, A. and Fine, R. (ed)
Handbook of Dialysis Therapy. Fourth Edition. Saunders: 2007
Ash, S.R. & Daugirdas, J.T. Peritoneal Access Devices. In Daugirdas, J. T., Blake, P.G. & Ing, T.S.
Handbook of Dialysis. Fourth Edition. Lippincott, Williams & Wilkins: 2006
Baxter Healthcare Corporation. (2009). Doing Dialysis at Home, Lesson 2.
Brothy, P. D. & Jetton, J. G. (2011). Pediatric acute kidney injury: Indications, timing, and choice for
modality for renal replacement therapy. Retrieved from Up to Date, July 13, 2011.
Centres for Disease Control and Prevention. Guidelines for the Prevention of Intravascular CatheterRelated Infections. MMWR 2002; 51(No. RR-10). Retrieved September 7, 2011 from
www.cdc.gov/mmwr/PDF/rr/rr5110.pdf
Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16). Retrieved
September 7, 2011 from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
Firanek, C. & Guest, S. (2011). Hand Hygiene in Peritoneal Dialysis. Peritoneal Dialysis International.
31(4):399-408
Furman, K.I. et al. (1978). Activity of intraperitoneal heparin during peritoneal dialysis. Clinical
Nephrology. 9(1), 15-8.
Gokal, R., Alexander, S., Ash, S., Chen, T.W., Danielson, A., Holmes, C., Joffe, P., Moncrief, J., Nichols,
K., Piraino, B., Prowant, B., Slingeneyer, A., Stegmayr, B., Twardowski, Z., and Vas, S. (1998).
Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update.
Peritoneal Dialysis International. 18(1), 11-33.
Established: 1988
Reviewed: 01 FEB 2012
Page 22 of 24
PERITONEAL DIALYSIS
Gries, E. et al. (1989). Intraperitoneal heparin in peritoneal dialysis and its effect on fibrinopeptide A in
plasma and dialysate. Haemostasis. 19(1):21-5.
Hayes, D. D. (2003). Performing peritoneal dialysis: Clinical do’s and don’ts. Nursing 2003, 33(3), 17-18.
Heimbürger, O. & Blake, P.G. Apparatus for Peritoneal Dialysis. In Daugirdas, J. T., Blake, P.G. & Ing, T.S.
Handbook of Dialysis. Fourth Edition. Lippincott, Williams & Wilkins: 2006
Holley, J.L., Golper, T.A. and Post, T.W. (2009). Placement and maintenance of the peritoneal dialysis
catheter. UpToDate Online 17.2.
Home Choice, Home Choice Pro Automated PD Systems: Patient At-Home Guide. Ending your therapy.
6.1-6.4, Baxter Corporation. (2006)
Lew S et al. Disinfection of lines and transfer sets in peritoneal dialysis. Ronco, C., Mishkin, G.J. (Eds):
Disinfection by Sodium Hypochlorite: dialysis applications. Contributions to Nephrology. 2007. Vol
154, pp129-138.
Li et al. Peritoneal Dialysis-Related Infections Recommendations: 2010 Update. Peritoneal Dialysis
International, 2010.
Milonovich, L. & Kline, A. Renal System. In: Slota, M. C., editor. Core Curriculum for Pediatric Critical Care
Nursing. 2nd Edition. 2006. 408 – 445.
Patient First. Lesson 2: Doing dialysis at home. Baxter Corporation. (2009)
Piraino, B., Bailie, G.R., Bernardini, J., Boeschoten, E., Gupta, A., Holmes, C., Kuijper, E.J., Li, P.K., Lye,
W.C., Mujais, S., Paterson, D.L., Fontan, M.P., Ramos, A., Schaefer, F. and Uttley, L. (2005).
Peritoneal dialysis-related infections recommendations: 2005 update. Peritoneal Dialysis
International. 25(2), 107-31.
Piraino, B., Bernardini, J. and Bender, F.H. (2008). An analysis of methods to prevent peritoneal dialysis
catheter infections. Peritoneal Dialysis International. 28(5), 437.
Prowant, B.F. and Twardowski, Z. J. (1996). Recommendations for exit care. Peritoneal Dialysis
International. 16(Supp3), S94-9.
Prowant B.F. et al. (1989). Peritoneal dialysis transfer set change procedures study. ANNA J. 16 (1), 23-6.
Strippoli, G.F., Tong, A., Johnson, D., Schena, F.P. and Craig, J.C. (2004). Antimicrobial agents to prevent
peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. American
Journal of Kidney Diseases. 44(4), 591-603.
Warady, B.A., Schaefer, F., Holloway, M., Alexander, S., Kandert, M., Piraino, B., Salusky, I., Tranaeus, A.,
Divino, J., Honda, M., Mujais, S. and Verrina, E. (2000). Consensus guidelines for the treatment of
peritonitis in pediatric patients receiving peritoneal dialysis. Peritoneal Dialyisis International. 20(6),
610-24.
Wong, F.S.Y. (2003). Use of Cleansing Agents at the Peritoneal Catheter Exit Site. Peritoneal Dialysis
International. 23(S2), 148-152.
World Health Organization World Alliance for Patient Safety, First Global Patient Safety Challenge Core
Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and
their consensus recommendations, 2009
Established: 1988
Reviewed: 01 FEB 2012
Page 23 of 24
PERITONEAL DIALYSIS
APPENDIX A: HOW TO CULTURE AN INCISION OR WOUND
1. CLEAN incision/wound of any debris or pus, bacterial buildup or necrotic tissue with normal saline.
Irrigate the wound if needed.
2. ALLOW the incision/wound to air dry.
3. SWAB the incision/wound with a sterile culture swab. Gather fluid from inside the incision/wound and
along the edges if applicable by ROTATING the tip of the swab over a 1 cm2 area of the wound using
sufficient pressure to express fluid from within the wound tissue.
Rationale: This technique is believed to be more reflective of tissue bioburden than swabs of
exudate or swabs taken with a broad Z-stroke. Theoretically, this technique, known as the
Levine technique, is the best technique for wound swabbing, provided the wound is cleansed
first and the area sampled is over viable tissue, not necrotic tissue or eschar.
4. PLACE the culture swab into the tube with medium.
5. LABEL specimen and requisition with:
a. patient identification
b. location and type of wound (eg. post surgical incision, cellulitis, pressure ulcer)
c. antibiotics the patient is receiving
d. collection date and time
e. patient diagnosis
6. PLACE specimen in biohazard transport bag and transport to lab promptly.
References:
Gardner, S.E., Frantz, R.A., Saltzman, C.L., Hillis, S.L., Park, H. and Scherubel, M. (2006). Diagnostic
validity of three swab techniques for identifying chronic wound infection. Wound Repair Regeneration.
14(5), 548-557.
Miscellaneous. (2004). Obtaining Wound Specimens: 3 Techniques. Advances in Skin and Wound Care.
17(2), 64-65.
APPENDIX B: PERITONEAL DIALYSIS EXIT SITE ASSESSMENT SCORING SYSTEM*
0 Points
No
1 Point
Exit only ( < 0.5 cm)
2 Points
Including part of or entire
Swelling
tunnel
No
< 0.5 cm
> 0.5 cm
Crust
No
< 0.5 cm
> 0.5 cm
Redness
No
Slight
Severe
Pain on Pressure
No
Serous
Purulent
Secretion
*Infection should be assumed with a cumulative exit-site score of 4 points or greater.
Reference:
Warady, B.A., Schaefer, F., Holloway, M., Alexander, S., Kandert, M., Piraino, B., Salusky, I., Tranaeus, A.,
Divino, J., Honda, M., Mujais, S. and Verrina, E. (2000). Consensus guidelines for the treatment of
peritonitis in pediatric patients receiving peritoneal dialysis. Peritoneal Dialysis International. 20(6),
610-24.
Established: 1988
Reviewed: 01 FEB 2012
Page 24 of 24